Review of "Experiences of Depression"

Experiences of Depression
reflects Sidney Blatt's long career. Blatt proposes a synthesis of two types
of depressive experience, namely the anaclitic and the introjective. He begins
with Freud's observations in 1895. This does not mean the Blatt gives only the
classic or Freudian psychoanalytic slant, but rather moves quickly into a more
contemporary view of these phenomenological dimensions. Mentioning these two
royal roads to depression, one of course must then hold that these are in some
way connected to the idea that impairments in the establishment and impairments
of the representation of care-giving relationships, not just Bowlby-like, but
more intricate than that, contributes to the etiology of the experience of mood
states that reflect on of the two, and the questionnaires Blatt and his group
developed with these as factors, the famous Depressive Experiences
Questionnaire (DEQ) and also object relations assessments.

As so often is the case, Blatt's view of depression
was colored by his early experience in training analysis, and two early index
clients, referred to often as representing the dichotomy, or rather the
thesis-antithesis-synthesis that would color his life work in the field.

From this epistemology thus emerges
his integrative theory that informs on what he believes are the typology of
human experience under the influence of the mood disorders, and are clearly
illuminated in the narrative of depressed patients, given in verbatim examples
throughout.

Early on, and beginning with the
Austrian Maestro himself, Blatt examines the classical beginnings of theory in
melancholia and mourning, moving on through Spitz and Wolf, Segal and
Winnicott, Klein, Abraham in counterpoint with each other, and after Rado, the
unitary theories of depression as postulated by Bibring, Fenichel, but with
reference to an acknowledgment of different developmental levels at which the
clients' experience occurred. The first was a primarily oral phenomenon, the
second a loss of self-esteem in the Oedipal experience. Ignoring the cultural
implications in those cultures that deny the Oedipal stage, and the feminist
critiques of such positions, this is the origin of ideas of subtypes of
depression emerging, one more primitive, one more advanced and involving views
of significant others.

In this way, Blatt began to
distinguish between a simple anaclitic depression and a more complex introjective
depression. The former arises from the disruption of the primary care giving
relationship with the primary object, the second from a harsh, punitive,
unrelenting critical superego that creates the feelings of worthlessness that colour
depression of this subtype, introjection referring to the superego development
of introjective identification, in this case of a harsh object.

Having then explained these in
detail, Blatt moves on to more contemporary theories of depression, as I
mentioned above, beginning with Bowlby, predictably, given his views above.
Moving on through Arieti and Bemporad's interpersonal model, and then of course
Aaron Beck's cognitive behavioural model, describing the initial idiosyncratic
cognitive schemas, and then the later more linear individual schemas, and then
specific primal mode theory, which supposes that on activation, draws on
congruent systems to implement the goal of the mode, with varying thresholds of
activation, and thus various intensities of outcome, not necessarily
dysfunctional. This all supposes an evolutionary value to such experience,
tolerating the propensity or at list the threatened risk of pathology in the
balancing of these higher functions and their value/threat, even if risky, in
responding to the force of evolutionary pressure. The mode is however in
reality a cognitive schema that derives from the interaction of proto-schemas
and congruent life experiences, a little reminiscent of other, earlier
psychodynamic formulations, and still congruent with Blatt's formulations given
that the core beliefs here include the self concept and the primitive views of
others. This lead Beck to his own dichotomy, namely two major personality
dimensions, sociality and individuality, which Blatt again likens to Arieti and
Bemporad, Blatt, and Bowlby.

Blatt then moves on to integration
of the theoretical perspectives that he has elaborated on, and to object
representation in depression, focusing on Klein, Segal and others of that ilk.
It's a brilliant chapter, a work that stands alone in the book, and the next
chapter focuses on the examples of how he and his colleagues see these two
types of depression expressed in the clinical context. This is done
extensively with detailed case histories, which dominate the chapter around the
anaclitic-introjective split.

Part two moves on to a discussion
of the value of assessing these modes of depression, and of the use of the DEQ
and the Object Relations Inventory (OBI). Two attempts were made to develop
measures, which evaluated the outcomes of care giving relationships in
depressed patients' histories.

The first (chapter three) was an
attempt to develop a systematic tool to provide a reliable and valid measure of
the two types of experience, and the second, chapter four, the development of
an OBI.

Akiskal and others have set out
over the years to examine the affective disorders across the unique and
disorderly spectrum that constitutes such illnesses. The amount of variance
within a category rivals the variance between categories, and in some cases is
wider, with all types of symptoms bleeding in to the primary ones, a mix of all
types of things is possible, in the Fulds-Bedford way. There is a need to
establish subtypes of depression that do not depend on such a wide spectrum of
symptoms, but on some other criteria.

To this end these devices are thus
created, including a DEQ for adolescents, loading strongly on three factors,
namely dependency, self-criticism and efficacy. The adult and adolescent items
look vaguely similar, but the important differences are also clear: however,
the factors are stable, and cluster around interpersonal and self-critical
issues. Connected to this are the subscales embedded in the first factor,
namely neediness and relatedness, factor two which is related to self
criticism, and factor three, lack of efficacy.

Other measures of the anaclitic-introjective
experiences are discussed, including the Sociotropy-Autonomy scale (recall
Beck) and the Personal Style Inventory, as well as the Dysfunctional Attitudes
Scale, all with their own psychometric problems. A tiny section dealing with
experiences of gender, race and social mobility is both fascinating and
hopelessly too short, given the nature of cross-cultural experience as well as
the influences of gender in society, but some other references follow in later
chapters.

Section three is composed of a
series of commentaries on the distal and proximal antecedents of the anaclitic
and introjective experiences within depression, both within clinical and
non-clinical groups, but with a particularly interesting section on depression
and substance abuse, but more substantially opiate addiction given the
centrality of depression on opiate use, across many pages. Non-clinical settings
are also expansively annotated here, with special focus on children and
adolescents. These extensive discussions have led to the author putting in a
summary, which is most needed given the plethora of research findings, which
beg an informed conclusion. Mostly, this gives Blatt an opportunity to
reinforce his beliefs, namely, that self-critical individuals are more
introverted, isolated and distant from others, and consequently their
interpersonal interactions are unpleasant, with the convergence then of several
measures of the introjective person. In contrast, on the DEQ, individuals with
elevated scores on the dependency-interpersonal factor tend to be the opposite.

The promised work on gender is here
too. Girls are more likely to report anaclitic depressive symptoms than boys,
especially with regard to somatic preoccupations, sad affect, and loneliness.
Boys are more likely to have externalizing disorders and report introjective
depressive symptoms that include antagonism, aggression and an inability to
work. "Differences in socialization may contribute to these gender
differences in the expression of psychological distress" (page 185). I
won't go there on feminist grounds, but will merely point out what Gilligan
said about it all: women speak with a different moral voice, not an incomplete Oedipal
accent.

In terms of the distal, or
developmental origins, as compared to proximal, or precipitating events,
chapter 6 focuses on negative caring experiences that create distortions in the
representation of self and others in interpersonal relationships. Chapter seven
then, on the much wider putative contextual experiences seen as proximal
causes, has a more reactive slant. Distortions of representation means the
individual will struggle to retain the necessary contact with the object, and
thus in introjective depression, elements of the individual will be sought
after without consolidation of the whole relationship, a kind of ambivalent,
replacing the need gratification as soon as possible with some other aspect or
some other object. There is a fair amount of reliance on research into the
mother here, as primary love object, as well as with retrospective studies on
parenting overall.

The proximal events chapter that
follows is only half as long, expected in a book with such an intrapsychic
slant to it.

In the concluding section, made up
of a chapter which considers the therapeutic implications of such theories,
Blatt examines the four above, namely Arieti and Bemporad, Beck, Blatt and
Bowlby, in terms of their influence on how one goes about the business of
therapy, and of course the inference is there in all four approaches of the
need to stress the centrality of impaired cognitive structures in depression.
Three concentrate on the therapeutic relationship, with experiences within
therapy contributing to a change in outcome, but all agree on the cognitive
aspects that require therapeutic change in mental representations.

An outstanding work if you follow
any of the four orientations, and certainly much more palatable if you have
more than just a working knowledge of twentieth century psychodynamic theory.
As with so many works, the Euro or Americo-centric version of the world is
rather amusing to those outside, from non-Western backgrounds, where seldom has
the psychodynamic view of the development of human cognitive and emotional
structure been uncritically accepted. I have had the opportunity to work with
people who believe that everyone we interact with in our day to day existence
is dead and a zombie, and that as individuals we do not exist at all, with one
brother confessing to a crime his brother committed, seeing no difference
between himself and even distant, but clan or skin related relatives. One child
I saw in Africa referred to multiple mothers and fathers, all of whom he
related to as a birth child, and if he had problems with Oedipus, it would have
been in the midst of a de-individuated mob seen with who knows what dynamics:
family therapy no good there either, he counted 91 first degree relatives
living in his family home, and my room was not that spacious.

However, within this genre, and even if you struggle
with psychodynamic principles, this is a master at work, and he makes it all
very easy to access and comprehend, and engenders a desire, just as Freud did
before him, to want to go right to work with this material and apply it to the
next client you see. Perhaps it is more so to me, being old enough to recall
being taught about the Wolf Boy, and certainly completing my MA degree in feminist
and family therapist criticisms of psychodynamic theory, and therefore still
part of my own psyche.

But especially for those who are
new to the area, this will fill a huge gap for them, and done so well, it is
both filling and fulfilling.